Most self-funded plans have their pharmacy rebates well in hand. The PBM captures them, reports on them, and everyone moves on. But there’s a second category of manufacturer rebate value that far fewer plans are capturing: the rebates owed on specialty drugs billed under the medical benefit.
These are the physician-administered specialty drugs: the infused and injected therapies that show up on medical claims rather than pharmacy claims. Because they sit outside the PBM’s lane, the rebate value tied to them often goes unrecovered, not because anyone made a bad decision, but because most rebate programs simply weren’t built to look there.
For third-party administrators and the self-funded employers they serve, that gap can represent a meaningful, recoverable opportunity, one that sits alongside existing pharmacy rebate arrangements without disrupting them. Recovering it doesn’t require changing PBMs, reworking claims workflows, or touching the member experience. It requires visibility into where the value is, tied to specific drugs and claims so the picture is transparent and defensible.
That’s the conversation we’re bringing to the HCAA TPA Summit in Nashville. We’ll be on the ground throughout the event, and we’d welcome the chance to compare notes with administrators and plan leaders on where medical-benefit rebate recovery fits into a smarter cost-containment strategy.
If you’ll be at the Summit and want to talk through the medical-benefit rebate gap for your book of business, we’d love to connect.